Julie Lager, MS, Department of Health&Kinesiology, Texas A&M University, 4243 TAMU, 158P Read Building, College Station, TX 77843-4243, 979-862-8574, jlager@hlkn.tamu.edu, Lori Keeling Buhi, MPH, Bryan-College Station Community Health Center, 3370 South Texas Avenue, Bryan, TX 77802, and Ranjita Misra, PhD, CHES, Health&Kinesiology Department, Texas A&M University, 4243 TAMU, 158P Read Building, College Station, TX 77843-4243.

In 1998, the Bureau of Primary Health Care established Health Disparities Collaboratives to change primary health care practices. In these collaboratives, Federally Qualified Health Centers across the United States work to eliminate health disparities and improve the quality of care for underserved populations with a specific chronic condition. The Bryan-College Station Community Health Center, a federally qualified health center in Texas, joined the Diabetes Health Disparities Collaborative in May 2003. Currently the BCSCHC serves over 10,000 unduplicated clients each year. The Center is employing a multidisciplinary approach to provide a comprehensive package of services to improve both functional and clinical outcomes for patients with diabetes. The Center is using three models – the Learning Model, the Chronic Care Model, and the Improvement Model – to transform the delivery of care for patients with diabetes. This presentation describes lessons learned from redesigning the Center’s health care delivery system. Specifically, successes and barriers will be shared on processes used to transform the system, including the implementation of group visits, which combine several components of care into one visit; establishing individual and group self-management education programs; encouraging patients to understand and participate in managing their own care; using an interactive clinical information system to provide proactive care and aid in patient follow-up; forming community linkages to provide support services and specialty care; and ensuring implementation of the latest evidence-based guidelines. In addition, practical advice will be offered in applying these lessons learned to other healthcare organizations.

Learning Objectives: By the end of this session, participants will be able to

• Understand three models used to transform the health care delivery system of a federally qualified health center,
• Articulate the benefits of engaging patients in their own care,
• Identify ways to improve health care organizations using a multidisciplinary approach,
• Apply components of the chronic care model and improvement model to diverse health care settings.

Keywords: Health Care Delivery, Quality Improvement

Presenting author's disclosure statement:
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: I am employed by the Bryan-College Station Community Health Center and serve as the team leader for the diabetes health disparities collaborative at the center